by David Balashinsky
As a physical therapist, one of my responsibilities - to my patients and to the profession - is to keep learning. Whether it's to learn about new developments in the field or treatment techniques with which I might not be familiar, I am obligated to take continuing education courses. (I am also legally required to do so, just as most licensed healthcare professionals are, as a condition for renewal of my license every three years.) These are generally lectures online or in person that can last from as little as a couple hours to several days and that cover myriad topics related to physical therapy.
Physical therapy, incidentally, is a great field, not least because it is so rewarding for the therapist and beneficial to the patient but because it addresses so many different types of diagnoses and encompasses so many different types of treatment techniques. Physical therapists treat patients with strokes, cancer, fractures, joint replacements, pelvic-floor dysfunction, neuropathies, vestibular problems, amputations and many other conditions, as well. They treat the young and the old, female, intersex, male, gay, straight, transgender, cisgender and everything in between and beyond. The number and type of continuing "ed" courses available, therefore, is as vast and diverse as the diagnoses and patient populations it is our privilege to serve.
One of the most serious types of injuries that physical therapists treat are spinal cord injuries. Most people are fortunate enough not to have to cope with the day-to-day challenges of living with a spinal cord injury (SCI) or even to think about what that might be like. The statistics, by themselves, do not adequately convey a sense of the gravity of this condition. For that, I encourage you to listen to first-person accounts of people living with SCI. But, for what it's worth, there are roughly 300,000 people with SCIs living in the United States. Interestingly, the sex identification of about 78% of all new reported cases of SCI (since 2015) is male. Motor vehicle accidents are the leading cause of SCI followed by falls, but other "common" causes are acts of violence (primarily gunshot injuries) and injuries resulting from sports and recreational activities.
The type and severity of SCIs are categorized according to a system of classification established by the American Spinal Injury Association (ASIA). This system, which is known as the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) is used throughout the United States and abroad and is considered "the gold standard" for SCI classification. (The ISNCSCI includes the ASIA Impairment Scale [AIS] but, although the AIS classification of SCI is derived from and, therefore, constitutes just one part - a major part but, still, only one part - of the battery of sensory and motor testing that comprise the ISNCSCI, in the jargon of healthcare "the ASIA" has come to be used to refer broadly to the ISNCSCI itself.)
I was introduced to the ISNCSCI and the AIS in physical therapy school but it was only an introduction. In a class on inpatient rehabilitation, we
watched a video that demonstrated how to perform the
elements of "the ASIA," one of which is to insert a gloved index
finger into an anus in order to check for sensation to deep anal pressure and voluntary
contraction of the external anal sphincter. (The thing I remember most
about this is one of my classmates asking if he could please watch that
part of the video again.) Like much if not most of what one learns in a physical therapy program, this was just an introduction to material that one cannot possibly hope to master without additional training and, above all, experience - preferably under the guidance of more experienced therapists. Although I have worked with SCI patients over the years, the inpatient rehabilitation facility (IRF) where I work does not typically receive patients during the acute phase of their (newly diagnosed) spinal cord injuries. Largely for this reason, I have not had occasion to use the ISNCSCI and have never acquired what I felt was a sufficient grasp of how to administer it and how to interpret its results. This is why I chose, a couple weeks ago, to enroll in a series of continuing ed courses devoted to SCI and to "the ASIA."
It was while taking these courses that I was reminded that there has been an effort underway by the leading authorities on SCI to replace the term "quadriplegia" - which is how most of us, at least here in the United States, know it - with "tetraplegia." These words mean the exact same thing and are defined as
impairment or loss of motor and/or sensory function in the cervical segments of the spinal cord due to damage of neural elements within the spinal canal. Tetraplegia results in impairment of function in the arms as well as typically in the trunk, legs, and pelvic organs. . . .
For a long time, I have been dimly aware of the fact that there is an official policy of preference for "tetraplegia" over "quadriplegia." Revisiting these topics, I discovered that the ISNCSCI explicitly says so. What I have not known is why. Seeing "tetraplegia" used again and again in these courses rekindled my interest in understanding the reason for this change in nomenclature. I was finally able to find an explanation for it on the website of the online organization, facingdisability.com:
We get asked about this subject a lot, “What’s the difference between quadriplegia and tetraplegia?”
Surprisingly, there isn’t any difference in meaning. Both words apply to paralysis of all four limbs. And both terms are used interchangeably these days.
The difference is in the derivation of the words. The word “Quadri” means four in Latin; the word “Plegia” means paralysis in Greek. So the roots of the word “quadriplegia” which means paralysis in all four limbs, come from both Latin and Greek. It combines two different languages.
The Greek word for four is “Tetra.” Combine that with “plegia” and you have a word with Greek roots for both halves. The British have always used the term “Tetraplegia” for four-limb paralysis, so they are not combining Latin and Greek words.
Such distinctions are important to the English, but Americans don’t seem to mind. Although there was a movement in the 1990’s to try to adopt “tetraplegia” in America, it never really caught on outside of the medical literature.
That’s why most Americans still continue to refer to “quad rugby,” for example, and why the word “quadriplegia” remains in common use.
Incidentally, since “para” is the Greek word for two, and “plegia” is Greek for paralysis the word “paraplegia” all comes from the same language of origin—Greek.
As much as I revere (and generally comport myself with due deference to) experts and expertise, I am also, by nature, highly skeptical of (and even hostile to) neologisms. This holds as much for those that fall from the spires of ivory towers as it does for those that arise from the propagation bed of vernacular. Learning the reason, therefore (and at long last), for the use of "tetra-" versus "quadri-"elicited from me an especially large eye-roll. Could the clash of civilizations that threatened to result from the pairing of the Latin "quadri-" with the Greek "-plegia" possibly matter less? Are the Barbarians - with their battle axes and their "quadri-" - not just at the gate but inside, and in need of expulsion? (Except, of course, that the Barbarians, in this case, are not the Greeks but the Romans themselves. And, in any case, the civilizations of antiquity frequently learned and borrowed from one another.)
I am a language purist as much as anyone but I am also an American: after this initial reaction, my patriotism took hold of me. I take pride in the fact that every person in this country is or is the descendant of immigrants, including Native Americans who were themselves "immigrants" in the Americas (long before they were "the Americas") many thousands of years before the Vikings and the Europeans were, and that, perhaps more than any other nation on Earth, the United States is woven from the myriad cultures, ethnicities, races and nationalities that make up the ornate tapestry of the American body politic. I admit it: I am one of those who believe that diversity is a positive good. When I was young, the concept of "the melting pot" was instilled in us as part of our civics instruction in elementary school. After Alex Haley (and many others) and the recognition that what "melting pot" really meant was Anglo-conformity, that metaphor was replaced by one which was much more apt. This one - "a gorgeous mosaic" - was popularized by David Dinkens, although apparently it was coined by Mario Cuomo, who referred to my home town, New York City, and to the United States as "a magnificent mosaic." This concept - the mingling of people and cultures as coequals in which their individual identities are retained and honored yet, at the same time, are subsumed within a single whole for the greater good - I believe is epitomized by the word "quadriplegia." It is a word that marries two languages and two cultures; it is like Cleopatra and Mark Antony. Opposition to the use of "quadriplegia" on the basis of its impurity seems as contrary to my view of people and America and is almost as offensive to my values as are anti-miscegenation laws.
Then, there is the problem that well-meaning efforts to change terminology often just fall flat for other reasons. The prefix "tetra" is undeniably beautiful in and of itself. It elicits associations with such naturally elegant structures as tetrahedrons and such beautiful creatures as "tetras" (short for tetragonopterus). Contrast "tetraplegia," however, with another recent effort to change the medical nomenclature from "stroke" (or cerebral vascular accident - CVA) to "brain attack." Yes, that really happened. A number of years ago, there was a similar effort to begin using "brain attack" to describe a stroke on the principle that the etiology (at least in the case of an ischemic stroke, which is caused by the obstruction of blood flow through an artery) is the same as that which results in a heart attack. (In contrast, a hemorrhagic stroke results from the rupture of a blood vessel so it's unclear to me whether "brain attack" advocates intended that this should refer to both ischemic and hemorrhagic strokes or merely to those that had in common with heart attacks a mechanism involving an arterial blockage.) Like "tetraplegia," "brain attack" never caught on, possibly because it sounds less like a medical diagnosis than like the title of a trashy 1950s science fiction movie. Still, this example should stand as a warning to all who would attempt to change diagnostic terms from those that are near and dear to our hearts to those that are alien.
Of course, most of the medical terminology that has come down to us comes from both Greek and Latin. Moreover, there are plenty of words in common use that combine Greek and Latin elements. Words such as "appendicitis," dehydration," and "mononuclear." "Mononucleosis" is created from first a Greek element (monos), then a Latin element (nucleus), and then another Greek element (osis). I don't see anyone rushing to purify these terms by converting them to either all-Greek-based or all-Latin-based elements.
For me, what matters most - what should matter most - is what people living with SCI themselves prefer. I sought the answer to that by joining several SCI support groups on Facebook, identifying myself as a physical therapist and posting a query as to whether anyone had a preference for either "quadriplegia" or "tetraplegia" and, if so, why. Although I did not get a large response (so my informal survey has no scientific validity whatsoever), the consensus seemed to be that we should leave well enough alone and stick with "quadriplegia." I did receive one particularly thoughtful and illuminating reply from someone who, though she had not herself sustained a spinal cord injury, was a close family member of someone who had. As it happens, she also identified herself as a Latin teacher and a classicist and she therefore began her response by acknowledging her familiarity "with the problematic Greek-and-Latin combining phenomenon in English words," adding that "it bothers some language fans more than others." (I replied that I could hardly imagine anyone being better suited to answer my question.) This respondent ultimately expressed a preference for "tetraplegia," explaining that "I favor 'tetraplegic' because it is unfamiliar-sounding and the first feeling I have on hearing it is curiosity, not fear."
What is notable about that response is that it validates this person's own feelings and lived experience relative to SCI, rather than falling back on deference to authority. That puts her sentiments in line with those who express a preference for "quadriplegia." Both are equally valid and it is my intention, going forward, to respect that preference, whichever it may be. None of what I have learned recently has undermined my belief that the right of patients and of all individuals to choose their own identifiers, names and designations (and, yes, even their own pronouns) should always be respected.
* * * * * * * * * * *
* * * * * * * * * * * *
* *
